Country context

India is experiencing a period of rapid health transition in which the burden of non-communicable diseases (NCDs) has surpassed that of communicable diseases. As of 2024, NCDs account for 63 percent of all deaths in India, making them the leading cause of death. Among NCDs, cancer is a significant driver of disability and mortality, with 1.6 million new cancer cases recorded every year in India, of which over 70 percent are diagnosed in advanced stages, reducing the likelihood of survival. Lung cancer is the fourth-most commonly diagnosed cancer, and second-most commonly diagnosed among men, with an overall incidence of 5.8 cases per 100,000 and a mortality rate of 5.3 per 100,000. However, these figures are likely to be under-representative, due to gaps in cancer surveillance and a low awareness of cancer symptoms, which acts as a barrier to diagnosis and treatment.

Despite its constitution guaranteeing the right to health for all, and requiring states to provide free health services, India does not yet have universal health coverage (UHC). Instead, its three-tiered health system is delivered by a mixture of private and public institutions. Public health facilities offer free or subsidized care to the poorest in society, and since 2017 this care has been supplemented by the public health insurance program Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). PM-JAY now enables about one-third of Indian households to access specialized treatment—including cancer care—and hospital admission free of charge. However, many Indians who are financially able choose to utilize private health care, as wait times are shorter, and the private sector offers access to innovative and advanced procedures and medicines. Cost, however, is a significant barrier to access, and fewer than one-third of Indian households have private health insurance. Out-of-pocket payments can be economically debilitating, and catastrophic medical expenses—defined as out-of-pocket health care costs exceeding 10 percent of total household income—push an estimated six million Indians into poverty each year.

Tobacco use, and particularly air pollution, are significant drivers of lung cancer and other respiratory diseases. India has the second-largest population of tobacco users in the world, with 24.3 percent of the population being smokers in 2022. In 2021, India was the second-largest producer of tobacco globally, making the tobacco industry a significant economic player capable of influencing public policy development and implementation. The economic burden of tobacco-related disease has been estimated at USD 22.4 billion annually.

Air pollution is a similarly major challenge for containment of respiratory diseases, including lung cancer. India’s entire population lives in areas where annual average particulate matter pollution (PM2.5) exceeds WHO guideline levels, and 21 of the world’s 30 most polluted cities are in India. In 2019, 11.5 percent of total disability-adjusted life years (DALYs) were attributable to air pollution, and 1.3 percent of those were directly due to lung cancer, while in the same year 17.8 percent of all deaths recorded were attributable to air pollution. Deaths due to household air pollution have decreased significantly since 1990. This downward trend correlates with the introduction of clean cooking programs, such as the Pradhan Mantri Ujjiwala Yojana, which transitions households to cooking with liquified petroleum gas, away from coal or wood. However, deaths due to ambient PM pollution and ozone pollution increased dramatically in the same period, by 115.3 percent and 139.2 percent, respectively, demonstrating that much more needs to be done to improve air quality across India and, thereby, reduce pollution-related risks of lung cancer.

Assessing policies and programs

India’s cancer control strategy has been governed by two key strategies since the 1980s, neither of which explicitly mentions or prioritizes lung cancer. The National Cancer Control Programme for India (NCCP) was launched in 1984 and was successively updated every few years to reflect evolving priorities. However, the most recent text of the NCCP does not appear to be publicly available online, and it no longer appears to act as the primary guiding strategy for cancer control in India. As of 2024, cancer control is integrated into the National Programme for Prevention and Control of NCDs (NP-NCD), which is part of the National Health Mission (NHM) launched in 2013. The NHM and its underlying strategies, including the NP-NCD, lay out objectives and goals for public health, which are then the responsibility of state-level health authorities to achieve, via state-specific strategies. States can apply for financial and technical assistance from the federal government to implement their strategies. Key priorities for the NP-NCD include strengthening health care infrastructure and human resources, improving prevention and early diagnosis, and accelerating treatment and referral processes. As part of the NHM’s drive to improve facilities and human resources, new Regional Cancer Centres (RCCs) are being established, and existing centers upgraded, in order to provide comprehensive treatment for all cancers and improve referral times. To be eligible for funding and support, facilities must meet requirements regarding the number of beds for cancer care, and possession of certain types of cancer treatment equipment. However, by leaving states to establish their own strategies, the NP-NCD risks exacerbating geographic disparities in cancer care.

There is currently no national lung cancer screening program, which undermines prevention and diagnosis, particularly due to low awareness of cancer symptoms among the Indian population. Diagnostics such as low-dose computed tomography (LDCT) and PET-CT are less effective in India due to the high prevalence of tuberculosis, presenting additional challenges to early and accurate diagnosis. While next-generation sequencing (NGS) and molecular diagnostic testing have been approved for cancer diagnosis, these technologies are currently only available in the private health sector and in select facilities in major cities, creating a significant cost-based barrier to access, and thus limiting their effect on public health. However, the Department of Health Research and Indian Council of Medical Research launched a new program in 2023 to extend biomarker testing for cancers, free of charge throughout the country. As of December 2023, at least 18 centers in the DHR-ICMR Advanced Molecular Oncology Diagnostic Scheme (DIAMoNDS) provided lung cancer biomarker screening specifically. Expanding access to, and guaranteeing, lung cancer screening free of charge could be a major factor in improving surveillance, early detection, and treatment in the future.

While cancer treatment in India is of high quality, often compared to that of high-income countries, household income level and geographic location remain significant barriers to effective care. There are over 500 radiotherapy facilities in India, but most are located in urban areas, creating an urban-rural treatment divide, while similarly the few specialized thoracic surgeons are based in urban centers. Meanwhile, although two forms of immunotherapy have been approved for use in cancer treatment, they are only available via the private health sector, creating a cost-based divide between those who can pay and those who cannot. Additionally, most Indian residents are unable to access innovative or experimental treatments, as few clinical trials are hosted within the country. Indeed, Indians represent only around 1.5 percent of global clinical trial participants, despite representing one-fifth of the global population. These factors help explain why Indian cancer and NCD strategies have emphasized the development of human resources and physical infrastructure for effective cancer care.

Beyond specific NCD-related strategies, a recent government initiative is also intended to dramatically reduce cost-based barriers to health care, including cancer treatment. The PM-JAY is India’s first public health insurance program, intended to eventually achieve UHC. It aims to be the world’s largest public health insurance program, and since 2018 it has offered over INR 500,000 (USD 6,002) per year to families of all sizes to cover secondary and tertiary care hospitalization and specialized medical care, including cancer care. Since 2017, the program has created 150,000 Health and Wellness Centres, intended to transform the delivery of primary care, including maternal and child services, prevention and treatment of NCDs, and diagnostics, by increasing access to health care centers, including in rural areas.

Following treatment, palliative care is guided by the National Programme for Palliative Care, but much like the NP-NCD, the national strategy is funded and implemented at the state level. The plan seeks to improve capacity to provide palliative care, with special attention to Indians over 60 years of age, and people with cancer or HIV/AIDS. One key goal of the Programme is to increase palliative care services in local and regional health centers, with the aim of reducing disparities of care based on geographic location.

India is also making a concerted effort to address lung cancer risk factors such as tobacco usage and air pollution. The Cigarette and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act (COPTA) was enacted in 2003. It introduced health warnings on tobacco products and banned smoking in public spaces, among other things. Successive amendments have strengthened tobacco control, including by increasing the size of pictorial health warnings and offering free smoking-cessation services in primary health care centers. In 2019, the excise tax rate on tobacco products was revised to 54 percent, although some experts advise increasing this further for greater effect.

These laws do not regulate the consumption of bidi—a cheap, unfiltered cigarette that is not manufactured, regulated, or taxed the same way as other cigarettes, and remains the dominant smoking product. Controlling the use of bidi warrants an approach more focused on education and awareness-building about the risks associated with lung cancer, and the further extension of support to help those who consume bidi to quit. Still, India’s legislative approach has had significant effect. Smoking rates decreased by 17.3 percent in 2016-2017 compared to 2010-2011, and India is on track to meet the 30 percent reduction target by 2025. Successfully meeting this target would contribute measurably to lung cancer control if the government can identify an effective method for reducing bidi consumption.

Air pollution in India is driven by a number of sectors, requiring a multistakeholder, multi-jurisdictional approach to its control and reduction. The government is trying to expand renewable energy—for example, through the Rewa Solar Project, which now supplies 60 percent of New Delhi’s daytime energy. In addition, the National Clean Air Programme (NCAP) has set clear, time-bound goals for improving air quality across the country, focused on 132 cities and towns with the worst air pollution. As part of this approach, in 2020 the government committed to spending USD 1.7 billion over five years within cities that reduce their air pollution levels by 15 percent each year. This initiative is the world’s first performance-based fiscal transfer program for air quality management in cities. Given the significant challenge that air pollution presents in India, data-driven targets and monitoring will be key to the success of anti-pollution strategies and policies. This will require improvements in the reliability, timeliness, and accessibility of air pollution data in order to hold the government accountable to its pledge. India’s continued industrialization and economic development will require the government to lead a concerted, multistakeholder effort to reduce associated air pollution as a means of controlling lung cancer.

FIGURE 2

GRIP: Gains, Risks, Innovations, Prospects in Policies and Programs

Opportunities ahead

Despite India’s progress in certain areas, significant gaps remain in its lung cancer control policy and implementation. Critically, the establishment of a lung cancer-specific strategy at the national and state levels is required and can be key to ensuring that this issue is prioritized and effectively addressed. Relatedly, improving national-level disease surveillance can enable the establishment and monitoring of clear, data-driven targets for lung cancer control. Impactful policies to significantly ease the lung cancer burden include increasing the price of cigarettes and bidis by 70 percent, as studies have shown that this could avert 10 to 26 percent of smoking-attributable deaths. In addition, easing regulations to encourage pharmaceutical trials to responsibly take place in India could enable patients to access innovative and effective treatments at lower cost, while supporting the ongoing development of India’s own pharmaceutical and health care industry. India’s position as a regional hub for pharmaceutical manufacturing could, in fact, be effectively leveraged for effective cancer control, through greater access—at lower cost—to generic cancer medications.

Finally, analyses since the launch of PM-JAY have found that while health insurance coverage has increased, the pace of progress is inadequate to achieve UHC by the 2030 SDG deadline. Ramping up the program could save lives, as could including innovative treatments and diagnostics such as immunotherapy, precision technologies, and NGS under the free and subsidized coverage offered. Beyond these innovations, PM-JAY could be most impactful by closing urban/rural divides in access to care, through the establishment and quality assurance of its Health and Wellness Centres.